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<br /> ---------- ------------ <br />I' - <br />I STATE OF MINNESOTA FOR BOARD USE ONLY <br /> GAMBLING CONTROL BOARD AMT. PAID <br />,e: BINGO HALL LICENSE APPLICATION - LG 300 II CHECK # <br /> 07/19/96 PART 1 OF 2 <br /> DATE <br />LICENSE NUMBER: BH013 EFFECTIVE DATE: 06/01/97 EXPIRATION DATE: 05/31/98 <br />lAME OF BINGO HALL Pot 0' Gold BINGO HALL PHONE NUMBER 612-631-1724 <br />STREET ADDRESS OF BINGO HALL 3776 Connelly <br />(!TY, STATE ZIP CODE Arden Hills MN 55I12 <br /> AILING ADDRESS OF BINGO HALL 3776 Connelly Arden Hills MN 55I12 <br />lypE OF BUSINESS Sole Proprietorship MN SALES & USE TAX ID # I1234I1 <br />NAME OF LEGAL OWNER OF BINGO HALL PROPERTY Goldie Siedow <br />IuSINESS MAILING ADDRESS 3776 Connelly PHONE 612-777-2971 <br /> Arden Hills MN 55I12 <br />~TTACH A COPY OF ONE OF THE FOllOWING SHOWING PROOF OF OWNERSHIP OF THE BINGO HALL PROPERTY: <br /> WARRANTY DEED, CONTRACT FOR DEED, PROPERTY TAX STATEMENT, OTHER <br />lAMES OF ALL OWNERS, OFFICERS, DIRECTORS, PARTNERS, MANAGERS AND SUPERVISORS <br /> oldie Siedow Sole Proprietor <br />ach person listed above must fill out a Bingo Hall Personnel Information, Form LG315 <br /> L UNIT OF GOVERNMENT ACKNOWLEDGEMENT <br />I -If the bingo hall is located within any city limits, the city* must sign the application. <br /> -If the bingo hall is located outside any city limits. the county* AND township** must sign <br /> the application. <br />I TOWNSHIP By signaillre below, the township <br /> acknowledges that the legal owner of the <br /> bingo hall is applying for a bingo hall <br />lity* or County** Name license within township limits. <br /> Township** Name <br />Arden Hills Ramsey NIA <br />Ignatpre of p.erson recei.ving application ;t. ~ Signature of person receiving application <br /> , ) <br />CJ Date Received Title-Township official Date Received <br />k (J/}1'/U~~J Ft!5S~11?7 Township is: Organized <br />I (J)'( 71JE.IJs.Vl~, = Unorganized <br /> _ Unincorporated <br />I <br />it <br />I J;J.J, J.-I-'1'1 <br />